Embracing Spectrum of Care To Promote Early-Career Veterinary Wellbeing
One of the wonderful things about being a veterinary student is having the opportunity to see some truly unique cases. Tertiary care facilities, where the majority of clinical rotation time is spent, allow students to assist in providing care to very complex and interesting cases. However, veterinary students are not often exposed to cases that they will see commonly in primary care practice. Further, because these facilities are focused on gold standard care, new graduates often feel uncomfortable offering a range of options for diagnostics and treatment.
This article explores why spectrum of care is so important for early-career professionals and tips to provide care along a spectrum.
Why Is Spectrum of Care Important?
Spectrum of care is not a new concept, but it has received increasing attention in recent years as part of discussions for improving access to veterinary care. The 2018 Access to Veterinary Care Coalition Report found 28% of pet owners had experienced a barrier to veterinary care in the preceding two years, and the most common barrier to care was financial limitations.
These barriers to care can lead to worse patient outcomes and can impact the mental health of both the veterinary team as well as the pet owners. The majority of veterinarians in this report agreed with the statement that “not being able to obtain needed veterinary care impacts pet owner’s mental and emotional health.” In addition, there is also a mental and emotional toll on veterinarians when clients are unable to afford care for a pet that has a treatable condition. When a veterinarian is unable to provide the care that they think is necessary, this can lead to a very specific kind of stress called moral distress.
Veterinarians may feel moral distress when they euthanize a dog or cat whose owner could not afford the treatment for potentially treatable conditions such as foreign bodies, parvovirus, or urethral obstruction. Facing these tough ethical dilemmas frequently may also contribute to burnout. Kipperman et al (2017) found that 77% of veterinarians felt that client financial limits contributed to their professional burnout. Learning to operate in the gray area of veterinary medicine and finding alternative approaches to care has the potential to not only improve the lives of our clients and patients, but it may also improve the mental health of veterinarians.
What Is Spectrum of Care?
Spectrum of care, as described by Fingland et al. (2021), is providing “a continuum of acceptable care that considers available evidence-based medicine while remaining responsive to client expectations and financial limitations.”
The spectrum of care reframes the way we look at care options for our patients. Instead of approaching every case with only gold standard treatment as a priority, practicing spectrum of care asks veterinarians to consider how to provide care along a continuum. Along this continuum, veterinarians will consider multiple options ranging from gold standard care and more aggressive diagnostics and treatments at one end of the spectrum to more basic and less-expensive options at the other. For a given condition, more basic treatment options could include a less intensive diagnostic workup, symptomatic treatment, or even benign neglect.
Spectrum of Care in Action
A 13-year-old female spayed Yorkshire Terrier presents with a cough. She has a history of a grade II/VI systolic heart murmur. On physical examination, you note crackles and a grade IV/VI heart murmur on auscultation. The gold standard approach would be to take chest radiographs to confirm the clinical suspicion of heart failure, obtain baseline blood work, start medications, and refer the patient for an echocardiogram with a board-certified cardiologist.
But what do you do for this client if they share that they only have $100 to spend on care?
Offering care along a spectrum allows veterinarians to work with our clients to find the diagnostic and treatment plan that fits the needs of our clients and patients. With $100 to spend, the veterinarian would still offer the client gold-standard care but would also discuss other conservative treatment options available. If the owner decides to pursue conservative treatment options, the veterinarian will then document in the record which options were offered as well as which options the client declined.
The needs of our clients are often based on finances, but we must also consider the emotional, physical, and mental needs of our clients. By forming a partnership with our clients, we can offer the best possible outcomes for our patients given the circumstances, thus meeting our moral and ethical obligations to our patients and upholding our oath to prevent and relieve animal suffering.
Barriers to Offering a Spectrum of Care
There are many potential barriers to offering a spectrum of care, many of which come from a place of fear. We fear a bad outcome for our patients if we do not follow the gold standard approach. We worry that clients will be upset and leave negative reviews or make a board complaint. In most cases, if we clearly communicate with clients, provide a variety of options, and have good record keeping, these things are less likely to happen.
Our own confidence, or lack thereof, in the early-career can be another barrier to offering a spectrum of care. Early-career professionals may worry that their physical examination skills are not refined enough to detect subtle abnormalities. They may rely more heavily on diagnostics because of this fear—I know that I did! Over time, veterinarians gain confidence and comfort in offering alternative options.
Finally, veterinarians often fear judgement from our colleagues if we practice below what they may consider standard of care. The difficulty with defining a standard of care comes from the fact that there is no profession-wide standard–it varies by location and type of practice. Block (2018) defines it as “the standard of care required of and practiced by the average reasonably prudent, competent veterinarian in the community.” As the spectrum of care becomes more widely discussed and accepted and research into alternative treatment plans grows, we hope that this judgment from our colleagues will be reduced.
Tips for Success Within the Spectrum of Care
The transition from veterinary student to veterinarian is exhilarating but simultaneously jarring and scary. As you move into clinical practice, here are some tips for successfully working within the spectrum of care:
Trust your physical examination, history, and signalment.
You can learn a lot from this information—there’s a reason our professors always grilled us on these facts for every case. Allow these things to guide the development of your differential list.
Think critically about diagnostic recommendations.
For each test you recommend, ask yourself what information you will gain and how that information will change your treatment plan. Many times, we need diagnostics to narrow down our differential diagnosis list, but sometimes we can get the information in another way (i.e., a mini chemistry panel instead of a full chemistry panel when our renal values and electrolytes are the values of concern in a blocked cat or a PCV and a blood smear instead of a full CBC).
Evaluate each case based on the patient in front of you.
While there is a wide range of options for any given condition, not every option is reasonable for every patient. An unstable patient will need more intensive therapy and potentially more diagnostics and monitoring than a stable patient with the same condition. Offering euthanasia for patients who are suffering when the owners cannot afford the recommended treatment is often appropriate, even though this can be a difficult discussion.
Be sure you are comfortable with the options you are offering.
Ultimately, you are the one in charge of the case. You must be comfortable with the treatment options offered. You will become more comfortable with a variety of treatment options over time. You can look to the literature, your own experience, and the experience of your colleagues to determine what options to present to the owner.
Offer all of the options and document everything.
Educate your client on the wide range of options available ranging from gold-standard to basic care. Guide the owner in the decision-making process, and help them determine what would be best for their pet given their individual circumstances. Be sure to document all the options offered in the record, which options were declined, and obtain informed consent for all diagnostics and treatments. If you are not comfortable with an owner’s decision to decline recommendations, you can ask them to sign an against medical advice form.
Communicate clearly the pros and cons of each option and the prognosis.
Communication is the key to success when working with clients. You can educate owners on why you are making specific recommendations, what they are giving up by selecting a different option, and what the prognosis is with each option. Being honest and open with clients about each option will ensure that both you and the client are comfortable with the choices made.
Be mindful of how you present options to clients.
Remember that communication goes beyond just the information that we present to clients. Good communication also includes how we present these options. Brown et al. (2021) discussed that the way options are presented to clients can influence not only which option a client chooses but how they feel about the options they choose. Being mindful of this can help improve outcomes and client comfort with the spectrum of options. I recommend always approaching these conversations with respect and empathy.
Debrief.
When we are unable to provide the care that we think is necessary for the patient, this can cause stress. It is important to seek help from others and debrief if you are having moral stress. The Veterinary Wellbeing Debrief is a fantastic tool for debriefing after these tough cases. In addition, consider seeking mentorship or peer support from others going through similar situations. You can gain peer support and veterinary mentorship from the MentorVet program!
A Few Final Thoughts
As a young veterinarian, it can be scary to offer options outside of what you were taught in veterinary school but learning to embrace spectrum of care will enrich your career. It allows us to improve the lives of more patients and clients by offering a range of options that fit their individual needs while maintaining our ethical duty to be an advocate for our patients and prevent and relieve their suffering.
References and Further Reading:
Kipperman BS, Kass PH, Rishniw M. Factors that influence small animal veterinarians’ opinions and actions regarding cost of care and effects of socioeconomic limitations on patient care and outcome and professional career satisfaction and burnout. J Av Med Assoc. 2017;250(7):785-794. https://doi.org/10.2460/javma.250.7.785.
Moses L, Malowney MJ, Wesley Boyd J. Ethical conflict and moral distress in veterinary practice: A survey of North American veterinarians. J Vet Intern Med. 2018;32(6):2115-2122. https://doi.org/10.1111/jvim.15315
Block G. A new look at standard of care. J Am Vet Med Assoc 2018; 252: 1343-44. https://doi.org/10.2460/javma.252.11.1343.
Brown CR, Garrett LD, Gilles WK, Houlihan KE, et al. Spectrum of care: more than treatment options. J Am Med Assoc. 2021;259(7):712-717. https://doi.org/10.2460/javma.259.7.712.
Fingland RB, Stone LR, Read EK, Moore RM. Preparing veterinary students for excellence in general practice: building confidence and competence by focusing on spectrum of care. J Am Vet Med Assoc. 2021;259(5):463-470. https://doi.org/10.2460/javma.259.5.463